Medi-Cal Long Term Care Programs, Benefits & Eligibility Requirements

Summary
Medicaid’s rules, benefits and name can all vary by state. In California, Medicaid is known as Medi-Cal. This article focuses on Medi-Cal Long Term Care for seniors, which will pay for care in nursing homes, beneficiary’s homes, assisted living residences and other settings through one of three programs – Nursing Home Medicaid, HCBS Waivers and ABD Medicaid. These programs are different from the regular Medicaid that is for financially limited people of all ages.

Medi-Cal (California Medicaid) Long Term Care Programs

Nursing Home / Institutional Medicaid

Medi-Cal (California Medicaid) will cover the cost of long-term care in a nursing home for financially limited California seniors who require a Nursing Facility Level of Care. Coverage includes payment for room and board, as well as all necessary medical and non-medical goods and services, such as:

• Personal care assistance with the Activities of Daily Living (mobility, bathing, dressing, eating, toileting)
• Skilled nursing care
• Physician’s visits
• Prescription medication
• Medication management
• Mental health counseling
• Social activities

Items not covered include a private room, specialized food, comfort items not considered routine (tobacco, sweets and cosmetics, for example) and any care services not considered medically necessary.

California Nursing Home Medicaid beneficiaries are required to give most of their income to the state to help cover nursing home costs. They are allowed to keep a “personal needs allowance” of $35/month, which can be spent on personal items such as clothes, snacks, books, haircuts, flowers, etc. They can also keep enough of their income to make Medicare premium payments if they are “dual eligible,” and enough to make any Medicaid-approved spousal income allowance payments to financially needy spouses who are not Medicaid applicants or recipients.

California Nursing Home Medicaid is an entitlement. This means all qualified applicants are guaranteed by law, aka “entitled,” to receive benefits without wait. However, not all nursing homes accept Medicaid, and those that do may not have any available spaces when you or your loved one needs care. So, eligible applicants are guaranteed nursing home coverage without wait, but they are not guaranteed coverage in any facility they choose.

Home and Community Based Services (HCBS) Waivers

Home and Community Based Service (HCBS) Waivers can pay for long-term care services and supports that help financially limited California seniors who require a Nursing Facility Level of Care (NFLOC) remain living the community instead of moving to a nursing home. The word “waiver” means something like voucher in this instance. Think of it as a voucher that will pay for long-term care services for California residents who live in their own home, the home of a loved one, senior housing, assisted living facilities or certain types of public housing. While California’s HCBS Waivers can pay for long-term care benefits in those settings, they will not pay for room and board costs such as mortgage payments, rent, utility bills or food expenses.

Unlike Nursing Home Medicaid, California HCBS Waivers are not an entitlement. Remember, entitlement means guaranteed by law. Instead, each HCBS Waiver program has a limited number of enrollment spots and once those spots are full, additional applicants will be placed on a waitlist.

California residents can receive HCBS Waiver benefits through the following programs:

1. Medi-Cal Assisted Living Waiver – covers long-term care services and supports for assisted living residents who require a Nursing Facility Level of Care (NFLOC)
2. Multipurpose Senior Services Program Waiver – covers long-term care services and supports for beneficiaries who require a NFLOC and live in their own home or the home of a loved one
3. Home and Community-Based Alternatives Waiver – covers long-term care services and supports for beneficiaries who are “medically fragile” and/or “technology dependent” and live in their own home, the home of a loved one or a congregate health facility
4. Community Based Adult Services – covers adult day care and day health care for beneficiaries with a medical need

1. Medi-Cal Assisted Living Waiver (ALW)
The Medi-Cal Assisted Living Waiver (ALW) covers long-term care services and supports for elderly (age 65 and over) and disabled California residents who need a Nursing Facility Level of Care but live instead in an Adult Residential Facility, Residential Care Facility for the Elderly or Public Subsidized Housing. While the ALW will provide benefits in these settings, it will not cover room and board costs.

ALW benefits include skilled nursing visits, medication oversight, meal delivery, homemaker services and personal care assistance with the Activities of Daily Living (mobility, bathing, dressing, eating, toileting). For Medi-Cal recipients who have been living in a nursing home for a minimum of 60 days and wish to return to the community, the ALW will provide transitional support like paying for movers, utility set-up fees and basic furnishings. ALW benefits will be made available depending on the needs and circumstances of each individual.

The ALW is available in 15 California counties – Alameda, Contra Costa, Fresno, Kern, Los Angeles, Orange, Riverside, Sacramento, San Bernardino, San Diego, San Francisco, San Joaquin, San Mateo, Santa Clara and Sonoma.

Multipurpose Senior Services Program (MSSP) Waiver
The Multipurpose Senior Services Program (MSSP) Waiver covers long-term care services and supports for California seniors (age 65 and over) who require a Nursing Facility Level of Care and live in their own home or the home of a loved one (friend or family member). The MSSP Waiver is also intended to help current nursing home residents transition back to their home or the home of a loved one. This Waiver is available in 45 counties in California. Click here to see if the MSSP Waiver is available in your county.

MSSP Waiver benefits include adult day care, home modifications, homemaker services, meal delivery, transportation, Personal Emergency Response Services, and personal care assistance with the Activities of Daily Living (mobility, bathing, dressing, eating, toileting). For MSSP beneficiaries who are leaving a nursing home and returning to the community, the waiver will cover transitional costs such as movers, utility set-up fees and basic furnishings. MSSP Waiver benefits are made available depending on the needs and circumstances of each individual.

The MSSP Waiver has a limited number of enrollment spots (around 11,300 per year as of 2024). Once those spots are full, additional eligible applicants will be placed on a waitlist.

Home and Community-Based Alternatives (HCBA) Waiver
California’s Home and Community-Based Alternatives (HCBA) Waiver covers long-term care services and supports for eligible California seniors who are “medically fragile” and/or “technology dependent” and live in their own home, the home of a loved one or a congregate living health facility (CLHF). Applicants who would require at least 60 days of nursing home or hospital care without the HCBA Waiver benefits are considered “medically fragile.” Individuals who need a mechanical ventilator, continuous air pressure support, tracheostomy respiratory support or an IV of medications or nutrition are considered “technology dependent.”

HCBA Waiver benefits include nursing services, home modifications, medical equipment expenses, Personal Emergency Care Services, and personal care assistance with the Activities of Daily Living (mobility, bathing, dressing, eating, toileting). While the HCBA Waiver will provide benefits in congregate living health facility, it will not cover room and board costs for the facility. For HCBA beneficiaries who are leaving a nursing homes and returning to the community, the waiver will cover transitional costs such as movers, utility set-up fees and basic furnishings. All HCBA Waiver benefits are made available depending on the needs and circumstances of each individual.

The HCBA Waiver has a limited number of enrollment spots (about 10,700 per year as of 2024). Once those spots are full, additional eligible applicants will be placed on a waitlist.

Community Based Adult Services (CBAS) Program
The Community Based Adult Services (CBAS) Program provides adult day care and adult day health care for California seniors at certified CBAS centers in 26 counties across the state – Alameda, Butte, Contra Costa, Fresno, Humboldt, Imperial, Kern, Los Angeles, Merced, Monterey, Napa, Orange, Riverside, Sacramento, San Bernardino, San Diego, San Francisco, San Mateo, Santa Barbara, Santa Clara, Santa Cruz, Shasta, Solano, Stanislaus, Ventura and Yolo. Seniors who live in a county without a CBAS center may use one in a different county if it is within a one-hour drive.

Not only do CBAS centers provide day-time supervision, they also offer meals, nursing services, care coordination, therapies, physical and social activities, and transportation to and from the center.

CBAS beneficiaries are allowed to need a Nursing Facility Level of Care (NFLOC), but it is not a requirement for the program. Conditions like chronic mental illness, brain injury, Alzheimer’s disease and other dementias may also qualify an individual. Medi-Cal uses a CBAS Eligibility Determination Tool to see if applicants meet the medical criteria.

Aged, Blind, and Disabled (ABD) Medicaid

California’s Aged, Blind, and Disabled (ABD) Medicaid provides healthcare coverage and long-term care services and supports to financially limited California residents who are aged (65 and older), blind or disabled. ABD Medicaid can sometimes be referred to as regular Medicaid for seniors, but it should not be confused with the regular Medicaid that is available for low-income people of all ages. ABD Medicaid is an entitlement, which means that anyone who meets the requirements is guaranteed by law to receive the benefits without any wait.

California ABD Medicaid beneficiaries who live in their own home or the home of a loved one and show a functional need for long-term care benefits can receive those benefits through the state’s In-Home Supportive Services (IHSS) program. There are four smaller programs within the IHSS:

1. Community First Choice Option – for ABD Medi-Cal beneficiaries who require a Nursing Facility Level of Care
2. Personal Care Services Program – for ABD Medi-Cal beneficiaries who need personal care assistance but do not require a Nursing Facility Level of Care
3. IHSS Plus Option Program – provides payment for spouses or adult children who serve as caregivers for Medi-Cal beneficiaries
4. IHSS Residual Program – provides a way for people who need IHSS care services but are not eligible for Medi-Cal to become eligible

Through one of these four programs, qualified California seniors can receive the following benefits:

• Personal care assistance with the Activities of Daily Living (mobility, bathing, dressing, eating, toileting)
• Homemaker services (housecleaning, laundry, shopping, errands, cooking)
• Paramedical services (wound care, catheter care, injection assistance, blood sugar checks)
• Protective supervision (supervision for mentally impaired people)
• Transportation assistance (to and from necessary medical appointments)

When a person enters the IHSS Program, they will be assessed to see what services they need and how often they might need those services to remain safe and healthy in their home. For program participants who do not have severe impairments, the maximum number of hours of IHSS Program care is approximately 195 per month, while people with severe impairments can receive up to approximately 283 hours of care per month.

For a list of county IHSS Program offices, go to this California Department of Social Services webpage.

California Advancing and Innovating Medi-Cal (CalAIM)
California ABD Medicaid beneficiaries, and other Medi-Cal recipients, who require a Nursing Facility Level of Care can also receive long-term care benefits through CalAIM. Program participants can live in their own home, the home of a loved one, an assisted living residence or a nursing home, as long as they are planning on returning to the community.

CalAIM offers two groups of benefits – Enhanced Care Management (ECM) and Community Supports (CS) – which include the following:

• Comprehensive and coordinated care management
• Referrals and coordination with social support services
• Assistance leaving a nursing home and returning to the community (paying for security deposits, set-up fees, and appliances related to health like hospital beds, heaters, air conditioners, etc.)
• Home modifications for safety and accessibility (wheelchair ramps, stair lifts, grab bars, etc.)
• Personal care assistance with the Activities of Daily Living (mobility, bathing, dressing, eating, toileting)
• Housekeeping services (shopping, cooking, cleaning, laundry)
• Medically tailored meals

Program of All-Inclusive Care for the Elderly (PACE)
California residents who are age 55 or older and have ABD Medicaid can cover their medical, social service and long-term care needs with one comprehensive plan and delivery system using the Program of All-Inclusive Care for the Elderly (PACE). PACE program participants are required to need a Nursing Facility Level of Care, but they must live in the community. California’s PACE programs can be used by people who are “dual eligible” for Medicaid and Medicare, and it will coordinate the care and benefits from those two programs into one plan. PACE also administers vision and dental care, and PACE day centers provide meals, social activities, exercise programs and regular health checkups and services to program participants. California’s PACE programs are located in Commerce (AltaMed PACE), Eureka (Redwood Coast PACE), Fresno (BoldAge PACE Fresno, WelbeHealth Fresno), Garden Grove (CalOptima Health PACE), La Quinta (WelbeHealth Inland Empire), Long Beach (WelbeHealth Long Beach), Los Angeles (InnovAge Crenshaw, myPlace Greater LA PACE), Merced (Central Valley PACE), Napa (Providence PACE), Newport Beach (Innovative Integrated Health), Oakland (Center for Elders’ Independence), Pasadena (WelbeHealth Pasadena), Reseda (Brandman Centers for Senior Care), Redlands (Loma Linda University Health PACE), Riverside (Neighborhood Healthcare PACE), Rohnert Park (AgeWell PACE), Sacramento (Sutter SeniorCare PACE and InnovAge California PACE – Sacramento), San Bernardino (InnovAge California PACE – San Bernardino), San Diego (St. Paul’s PACE and Family Health Centers of San Diego PACE), San Francisco (NEMS PACE and On Lok PACE), San Jose (WelbeHealth San Jose), San Marcos (Gary and Mary West West PACE), San Ysidro (San Diego PACE), Stockton (WelbeHealth Stockton), Victorville (High Desert PACE) and Visalia (Family HealthCare Network (FHCN) PACE. To learn more about PACE, click here.

Eligibility Criteria For Medi-Cal Long Term Care Programs

To be eligible for Medi-Cal a person has to meet certain financial requirements and functional (medical) requirements. The financial requirements vary by the applicant’s marital status, if their spouse is also applying for Medicaid and what program they are applying for – Nursing Home Medicaid, Home and Community Based Services (HCBS) Waivers or Aged, Blind, and Disabled Medicaid

Medi-Cal Nursing Home Eligibility Criteria

Financial Requirements
There are no financial eligibility requirements for nursing home coverage through Medi-Cal. However, California Nursing Home Medicaid beneficiaries are required to give almost all of their income to the state to help cover the cost of care. They are only allowed to keep $35/month of their income as a “personal needs allowance,” plus enough to make Medicare premium payments if they are “dual eligible,” and they can make any allowable spousal income allowance payments to financially needy spouses who are not covered by or applying for Medi-Cal.

California Nursing Home Medicaid applicants should also know that even though there is no asset limit, their assets are not protected from California’s Medicaid Estate Recovery Program. This program is required by law to try and collect reimbursement for long-term care after the death of Medi-Cal recipients. So, a senior may qualify for California Nursing Home Medicaid with a significant amount of assets, but they may not be able to pass those assets down as a family inheritance after their death. To learn more about Estate Recovery in California, click here.

In the past, the Look-Back Period prevented California Nursing Home Medicaid applicants from simply giving away their assets to become eligible for the program by looking back into their financial records for the 30 months prior to their application date. Now, because California has eliminated its asset limit as of Jan. 1, 2024, the state will not look into any of the applicant’s financial history after that date. However, transactions before Jan. 1, 2024, are still subject to a 30-month Look-Back Period.

For example, if a California senior applies for HCBS Waivers on March 1, 2025, the state will not look back into any part of 2025 or 2024, which would be a total of 14 months, but it will look back into the 16 months prior to Jan. 1, 2024. California’s Look-Back Period will eventually be phased out by July 2026. If the Look-Back Period is violated, the application will be denied and the applicant will face a penalty period of ineligibility.

Functional Requirements
The functional, or medical, criteria for Medi-Cal’s Nursing Home Medicaid is needing a Nursing Facility Level of Care (NFLOC), which means the applicant requires the kind of full-time care that is normally associated with a nursing home. To determine if an applicant requires a NFLOC, the state will evaluate their ability to complete the Activities of Daily Living (mobility, bathing, dressing, eating, toileting) and the Instrumental Activities of Daily Living (cleaning, cooking, shopping, paying bills, etc.), as well as any cognitive or behavioral issues. This can include Alzheimer’s disease and other dementias, but a diagnosis of Alzheimer’s or dementia does not guarantee a NFLOC designation.

Medi-Cal Home and Community Based Services (HCBS) Waivers Eligibility Criteria

Financial Requirements
California residents have to meet an income limit in order to be financially eligible for Home and Community Based Service (HCBS) Waivers. The income limit for a single applicant from April 2024 to March 2025 is $1,732/month. Almost all income is counted – IRA payments, pension payments, Social Security benefits, property income, alimony, wages, salary, stock dividends, etc. To understand exactly how your income might impact Medicaid eligibility, consult with a professional like a Certified Medicaid Planner or Elder Law Attorney.

For married applicants with both spouses applying, the income limit for HCBS Waivers in California from April 2024 to March 2025 is a combined $2,352/month. For a married applicant with just one spouse applying for HCBS Waivers, the income limit for the applicant spouse is $1,732/month and the income limit of the non-applicant spouse is not counted.

Functional Requirements
The functional, or medical, criteria for Medi-Cal’s HCBS Waivers is needing a Nursing Facility Level of Care (NFLOC), which means the applicant requires the kind of full-time care that is normally associated with a nursing home. To determine if an applicant requires a NFLOC, the state will evaluate their ability to complete the Activities of Daily Living (mobility, bathing, dressing, eating, toileting) and the Instrumental Activities of Daily Living (cleaning, cooking, shopping, paying bills, etc.), as well as any cognitive or behavioral issues. This can include Alzheimer’s disease and other dementias, but a diagnosis of Alzheimer’s or dementia does not guarantee a NFLOC designation.

California Aged, Blind, and Disabled (ABD) Medicaid Eligibility Criteria

Financial Requirements
California residents have to meet an income limit in order to be financially eligible for Aged, Blind, and Disabled (ABD) Medicaid. The income limit for a single applicant from April 2024 to March 2025 is $1,732/month. Almost all income is counted – IRA payments, pension payments, Social Security benefits, property income, alimony, wages, salary, stock dividends, etc.

For married applicants with both spouses applying for California ABD Medicaid, the income limit from April 2024 to March 2025 is a combined $2,352/month. For a married applicant with just one spouse applying, the income limit is $2,332/month and the income of the non-applicant spouse is not counted.

California ABD Medicaid applicants should know that even though there is no asset limit, their assets are not protected from California’s Medicaid Estate Recovery Program. This program is required by law to try and collect reimbursement for long-term care after the death of Medi-Cal recipients. So, a senior may qualify for Medi-Cal with a significant amount of assets, but they may not be able to pass those assets down as a family inheritance after their death. To learn more about Estate Recovery in California, click here.

Functional Requirements
The only functional requirement to receive basic healthcare coverage – physician’s visits, prescription medication, emergency room visits and short-term hospital stays – through California ABD Medicaid is being aged (65 and over), blind or disabled. For ABD Medicaid applicants and beneficiaries who require long-term care services and supports, the state will administer an assessment of their ability to perform Activities of Daily Living (mobility, bathing, dressing, eating, toileting) and Instrumental Activities of Daily Living (which include shopping, cooking, housekeeping and medication management) to determine the kind of long-term care benefits the state will cover. Behavior and cognitive issues will also be considered.

Qualifying with Medicaid Planning

California residents who are over their income limit for HCBS Waivers or ABD Medicaid can use the Medically Needy Pathway to reduce their income and become eligible. It works like an insurance deductible. Medi-Cal applicants/beneficiaries must pay for their medical expenses during their “spend down period” until they meet their “spend down” amount, which is calculated using their income and California’s Medically Needy Income Limit, which is $600 for an individual and $934 for a couple. Once they have reached their spend down amount, Medicaid will cover their medical expenses for the remainder of the spend down period, which is one month in California.

These Medicaid Planning strategies tend to be complicated, so consulting with a professional like a Certified Medicaid Planner or an Elder Law Attorney before attempting any of them on your own is recommended.

Applying For Medi-Cal Long Term Care Programs

The first step in applying for a Medi-Cal Long Term Care program is deciding which of the three programs discussed above you or your loved one want to apply for – Nursing Home Medicaid, Home and Community Based Service (HCBS) Waivers or Aged Blind and Disabled Medicaid.

The second step is determining if the applicant meets the financial and functional criteria, also discussed above, for that program. Applying for Medi-Cal when not financially eligible will result in the application, and benefits, being denied.

During the process of determining financial eligibility, it’s important to start gathering documentation that clearly details the financial situation for the Medi-Cal applicant. These documents will be needed for the official Medi-Cal application. Necessary documents may include tax forms, Social Security benefits letters, deeds to the home, proof of life insurance and quarterly statements for all bank accounts, retirement accounts and investments. For a complete list of documents you might need to submit with your Medicaid Long Term Care application, go to our Medicaid Application Documents Checklist.

After financial eligibility requirements are checked and double checked, documentation is gathered, and functional eligibility is clarified, there are three ways a California resident can apply for Medi-Cal and the three long term care programs Nursing Home Medicaid, HCBS Waivers or ABD Medicaid – online, through the mail or in person. People who need help with the application process can call the Covered California Customer Service Center at 1-800-300-1506.

Once the application is received, it will usually take 45-90 days to be reviewed and approved or denied by the state. It’s also possible applications that are missing information or have mistakes will be returned.

For step-by-step guides to applying for each of the three types of Medicaid, just click on the name: 1) Nursing Home Medicaid 2) HCBS Waivers 3) ABD Medicaid.

Choosing a Medi-Cal Nursing Home

After being approved for Nursing Home Medicaid through Medi-Cal, seniors need to choose which Medicaid-accepting nursing home best meets their needs. Even though Nursing Home Medicaid is an entitlement, not all nursing homes take Medi-Cal, and those that do may not have available spaces. Sometimes it can be difficult or time-consuming to find a residence that meets your needs, especially if you are looking in a specific geographic area.

There are approximately 1,230 licensed long-term care facilities in California, which includes both free-standing nursing homes and facilities that are attached to hospitals, which are referred to as “distinct part” nursing homes.

There are almost 400 long-term care facilities in Los Angeles County, and about 200 combined in Orange County, San Bernardino County and Riverside County. Plus, San Diego County has around 80 facilities. The San Francisco Bay Area has roughly 200 total facilities, with most of them in the East Bay (about 100 combined between Alameda County and Contra Costa County) and the South Bay (roughly 50 in Santa Clara County). The options start to narrow in the valley, where there are about 70 facilities combined between Fresno County, Kern County, Tulare County and Kings County. Facilities are even harder to find in Northern California, with around 20 combined between Shasta County, Humboldt County, Mendocino County and Trinity County (one).

If you have multiple nursing home choices in your area, you should start comparing them see which one meets your needs. Cal Health Find provides government ratings for all of its facilities, as well as information about complaints, deficiencies and enforcement actions. The search on Nursing Home Compare can be filtered by overall rating, health inspections, staffing and quality measures. The healthcare professionals who work with you can also be a great source of information. And the California Department of Aging has links to multiple resources and other sources of information.

After doing your research, you or someone you trust should also visit any nursing homes you’re considering before making a final decision. Call first to make an appointment for the visit, and arrive prepared with a list of questions. Some things you might ask are: Does the residence coordinate social activities? Does it provide transportation? Who are the staff doctors? What are the meals like? How will the residence provide access to oral and eye care? CMS has a thorough “Nursing home checklist” you can use to evaluate a nursing home while visiting.

California nursing homes undergo annual inspections that typically last three days and involve three or more state inspectors. Data collected by CMS reveals that California nursing homes reported an average of 47.1 health citations from 2018-2023, which is well above the national average of 27.2. And they reported an average of 21.6 fire safety citations, which is above the national average of 13.5. On a more positive note, California nursing homes averaged 4.4 nurse staffing hours per resident day, meaning each resident received an average of 4.4 hours of nurse attention per day, which is above the national average of 3.8.